A systematic review of the effects of strength training in

REVIEW Open Access

A systematic review of the effects ofstrength training in patients withfibromyalgia: clinical outcomes and designconsiderationsAlexandro Andrade1,2* , Ricardo de Azevedo Klumb Steffens1,2,3 , Sofia Mendes Sieczkowska1,2 ,Leonardo Alexandre Peyré Tartaruga4,5 and Guilherme Torres Vilarino1,2

Abstract

Background: Fibromyalgia (FM) is characterized by chronic and generalized musculoskeletal pain. There is currentlyno cure for FM, but palliative treatments are available. One type of treatment is strength training (ST). However,there is a need for more information on optimal training protocols, intensity, and volume needed to improvesymptoms. The aim of this study was to analyze the effects of ST in the treatment of FM through a systematicreview of experimental research.

Methods: Medical Subject Headings search terms and electronic databases including Scientific Electronic LibraryOnline, PubMed, Science Direct, Web of Science, and Physiotherapy Evidence Database were used to identifystudies.

Results: The inclusion criteria were met by 22 eligible studies. Most of the studies were conducted in the UnitedStates (36%), Finland (23%), Brazil (18%), and Sweden (18%). The studies showed that ST reduces the number oftender points, fatigue, depression, and anxiety, and improves sleep quality and quality of life in patients with FM.The intervention period ranged from 3 to 21 weeks, with sessions performed 2 times a week in 81.81% of thestudies, at initial intensities of 40% of 1-repetition maximum. The repetitions ranged from 4 to 20, with no specificprotocol defined for ST in FM.

Conclusion: The main results included reduction in pain, fatigue, number of tender points, depression, and anxiety,with increased functional capacity and quality of life. Current evidence demonstrates that ST is beneficial and canbe used to treat FM.

Trial registration: CRD42016048480.

Keywords: Fibromyalgia, Resistance training, Health, Exercises, Therapy, Rehabilitation

BackgroundFibromyalgia (FM) is a chronic disease characterized bygeneralized skeletal muscle pain [1, 2], and other com-mon symptoms include fatigue, sleep disorders, depres-sion, and excessive anxiety [3–6]. The pathogenesis ofFM is still not well understood [7], and FM is

considered by some researchers to be a neurobiologicaldisease caused by abnormal processing of pain [8].Owing to the lack of markers that can identify the dis-ease, the diagnosis is made through clinical examin-ation, according to the guidelines of the AmericanCollege of Rheumatology [1, 3].As FM has no cure, treatments are palliative, and

multidisciplinary approaches involving the use of medi-cations, physical exercise (PE), and psychological treat-ments are recommended [4, 9–12]. PE has been advisedin several studies and guidelines for the treatment of FM

* Correspondence: [email protected] and Sports Science Center, CEFID / Santa Catarina State University –UDESC, Florianópolis, SC, Brazil2Laboratory of Sports and Exercise Psychology - LAPE, Florianópolis, SC, BrazilFull list of author information is available at the end of the article

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[13–16], and the inclusion of aerobic, resistance, andwater exercises has been strongly recommended [5, 15–17]. The severity of FM symptoms can affect the level ofphysical fitness, and patients commonly perform littlephysical activity because of pain [18–20].The relationship between PE and FM has been investi-

gated, and strength training (ST) has been comparedwith other PE modalities. Studies have shown that SThas favorable results on pain, sleep, depression, and thenumber of tender points [17, 21]. However, studies onthe effect of PE present poor quality evidence owing tosmall sample sizes and methodological problems [22,23]. Recent studies have attempted to better understandthe effects of ST in patients with FM [21, 24–26]. How-ever, research has emphasized physical aspects with con-flicting results [27, 28]. Despite recent research on theeffects of ST in patients with FM, the duration, fre-quency, and intensity required to improve the symptomsremain unknown because the protocols differ amongstudies [29–31]. Thus, there is no consensus on the useof ST in clinical practice. The aim of this study was toanalyze the effects of ST in the treatment of FM througha systematic review of experimental research.

MethodsThe present study followed the PRISMA (Preferred Report-ing Items for Systematic Reviews and Meta-Analyses)guidelines [32]. The PRISMA Statement is a protocol thatguides the construction of systematic reviews in a transpar-ent and consistent manner using a checklist of 27 itemsand a 4-phase flow diagram [33]. This systematic reviewwas registered as CRD42016048480 in the InternationalProspective Register of Systematic Reviews (PROSPERO)[34]. A primary goal of PROSPERO is to make known theintention to conduct a systematic review, in order to re-duce duplication and to facilitate transparency in the re-view process [35].

Eligibility criteriaIn order to include the entire publication period, notime limit was set. The eligibility criteria were deter-mined according to the PICOS (Population, Interven-tion, Comparison, Outcomes, Setting) strategy.

PopulationAdults 18 years and older with a diagnosis of FM ac-cording to the 1990 criteria of the American College ofRheumatology (1).

InterventionAny intervention with ST or resistance training for pa-tients with FM was included. We excluded studies withcombined interventions, such as those with ST com-bined with aerobic training.

ComparisonWith any other type of group (such as sedentary con-trols and healthy controls) and with other types of inter-vention (such as aerobic exercise and flexibility exercise).

OutcomesAll possible effects of ST and the intervention protocolsused in the studies in patients with FM.

Type of studyRandomized or non-randomized trials reporting clinicaloutcomes demonstrating the effects of ST. The fre-quency of ST and the extent to which ST was providedwere the minimum necessary data for a research to bedefined as an intervention study. Revised articles, disser-tations, theses, and congress abstracts were excluded.

Information sourcesThe studies were identified through electronic databases,including PubMed, Science Direct, Web of Science,Physiotherapy Evidence Database, and Scientific Elec-tronic Library Online. The last survey was conducted inDecember 2017.

Search strategyThe search terms were defined by the researchers using theMedical Subject Headings (Table 1), and the search strat-egy in the PubMed database is shown in Additional file 1.

Study identificationThe searches and selection of articles were independ-ently performed by 2 researchers; in case of disagree-ment, a third party was asked to make the final decision.An initial analysis was performed based on reading thetitle. From these selected articles, the abstracts were readand the articles included in the review were read in theirentirety. A review of the references and citations of thesearticles was also carried out in order to identify otherpotentially relevant studies. From the selected studies,an analysis of the use of ST for the treatment of patientswith FM was performed.

Data extractionFor the analysis and discussion of the results, the follow-ing data were extracted: author and study design; studyparticipant number, age, sex, and treatment group; typeof exercise, time of intervention, intensity, and adher-ence (based on either the number of attending patientsat the beginning and end of the study or from data pro-vided by the authors); and conclusions of the study.

Quality of study and risk of BiasThis systematic review evaluated the quality of the in-cluded studies and the risk of bias using the Cochrane

Andrade et al. Advances in Rheumatology (2018) 58:36 Page 2 of 14

Collaboration Risk of Bias tool [36], which includes cri-teria to identify bias in the selected studies that caninterfere with the interpretation and conclusion. Biasrisk assessment was performed by 2 researchers. Thekappa concordance index [37] between the reviewersfor each of the criteria was determined, and differenceswere resolved by consulting a third reviewer for a finalopinion.

ResultsIdentification and selection of studiesThe first stage of selection using the databases identified211 studies, with 1 additional study manually inserted.Sixty-two duplicate studies were excluded and 48 ab-stracts were selected after reading the titles. At the ab-stract review stage, 17 studies were excluded, of which 9used combined exercise, 7 were congress abstracts, and1 did not evaluate patients with FM. In the fourth stage,the complete texts of 31 studies were read; 5 were ex-cluded because of the intervention protocol, 1 was ashort communication, and 1 was a congress article.Thus, 22 studies were selected for the analysis, as shownin Fig. 1.

Characteristics of included studiesOf the 22 studies included in the review, the oldest waspublished in 2001 [38] and the most recent was pub-lished in 2017 [24, 39, 40] (Table 2). Most of the studieswere conducted in the United States (36%, n = 8),followed by Finland (23%, n = 5), Brazil (18%, n = 4),Sweden (18%, n = 4), and Turkey (5%, n = 1). Womenaged 18–65 years comprised the total sample, and themain variables analyzed were pain, strength, muscularactivity, functional capacity, fatigue, quality of life, andsleep [24, 25, 27, 29, 38, 39, 41–44]. Among the testsused in the evaluations, the Fibromyalgia Impact Ques-tionnaire, which evaluates the impact of FM on qualityof life, was used in most of the studies [25, 27–29, 31,45–48]. To measure strength, the 1-repetition maximum(1RM) was the most used test [27–29, 31, 38, 49, 50]and studies that verified muscle activity used electro-myography [38, 41, 51–53]. The visual analogue scalewas used to evaluate pain in most of the studies [29, 41,42, 45, 48, 53]. Concerning adherence, most of the stud-ies did not provide this information. Therefore, adher-ence was calculated based on the patients’ attendance,

and an average adherence percentage of 84% (range, 54–100%) was obtained. Five studies provided the averageattendance rate, ranging from 71 to 100%.

Summary of evidence and practical implicationsThe analysis of the results revealed that ST reduced thesymptoms of patients with FM, such as pain, fatigue,number of tender points, depression, and anxiety, withimproved functional capacity and quality of life [24, 25,27, 29, 38, 39, 41, 42] (Table 2), despite the differenttraining protocols used.When analyzing the training protocol, 81.81% of the

studies submitted the patients to interventions twice aweek, whereas only 13% (3 studies) submitted the pa-tients to 3 sessions per week and 1 study verified the ef-fect of a single session. Concerning the interventiontime, the shorter studies lasted for 3 weeks whereas thelonger studies lasted for 21 weeks. Most of the studieshad an intervention time of 21 (22.72%), 12 (22.72%), 16(18.18%), and 15 (18.18%) weeks. The studies used simi-lar training protocols, starting with 40% of 1RM andprogressing to 85%. During the training, exercises usingmachines and free weights worked the large and smallmuscle groups.Pain was the most studied variable, showing a reduction

after ST [27, 29, 30, 45, 53–55]. No study reported in-creased pain after or during the intervention period. Kayoet al. [48] found at the end of 16 weeks of interventionthat only 41.4% of patients in the ST group were usingpain medication, whereas in 80% of the patients in thecontrol group regularly used pain medication. Otherwell-analyzed variables were strength, quality of life, heartrate variability (HRV), and depression. With regard tomuscle strength, increases between 33 and 63% were ob-served after 21 and 16 weeks [41, 49]. In terms of the vari-ability of heart rate, the effects of ST on patients with FMpresented controversial results; however, the evidenceshows little effect on this variable [49]. Studies analyzingquality of life and functionality showed that ST is effectivein improving these variables [28, 29, 31, 41, 42, 45].The most investigated psychological variable was de-

pression. The studies of Jones et al. [45], Gavi et al. [29],and Assumpção et al. [40] showed that ST reduces de-pressive symptoms; however, the study of Ericsson et al.[25] did not find a significant difference after 15 weeksof intervention.We also analyzed the results related to sleep quality.

Andrade et al. [24] found that sleep disorders were re-duced after ST and that sleep correlated with pain. Theresults of Ericsson et al. [25] also disclosed that STyielded better results than relaxation sessions in improv-ing sleep quality. In addition, another important result isthat patients with FM presented similar responses to

Table 1 Search terms used in databases

Terms Descriptors

1. Disease “Fibromyalgia”

2. Exercise “Resistance Training” OR “Strength Training” OR “StrengthTraining Program*” OR “Training Resistance” OR“Strengthening Program”

Combination #1 AND #2


those of healthy persons; thus, they recommended ST toassist in the treatment of patients.The intervention protocols, results, and conclusions of

each study are presented in Table 2.

Quality of studies and risk of BiasThe kappa concordance index between the two re-viewers was 87.1% for all criteria. Of the 22 studies, 13had low risk of adequate sequence generation bias; fourwere unclear regarding the risk of adequate sequencegeneration bias and six were not randomized. Only fourstudies had low risk of allocation concealment bias. Ten

studies had a high risk of blinded participant bias; onlyfour had a low risk and eight were unclear. Twenty-onestudies presented low risk of incomplete data bias. Simi-lar findings were noted for selective results bias; onlytwo studies were unclear. The descriptions of interven-tions (characteristics of exercises) were another sourceof bias, with only two studies having a high risk (Fig. 2).

DiscussionThis systematic review aimed to analyze the efficacy of STin the treatment of FM by examining the existing experi-mental research. The studies showed that the intervention

Fig. 1 Flowchart of the selection process of the reviewed articles for the review


Table 2 Characteristics and results of experimental studies with strength training for patients with fibromyalgia syndrome

Study andDesign

Sample Intervention Results Conclusion

Hakkinenet al., (2001);RCT

21 womenwith FM(ST and CG)e 12 HCAgeTF: 39 ±6 yearsCG: 37 ±5 yearsGS: 37 ±6 years

Duration: 21 weeks;Weekly frequency: 2;Repetitions: Initially15–20, from the 15thweek; 5–10Exercises: Supine, squats,extension and flexion ofknees and trunkAdherence to ST: 100%

FM subjects increased their maximaland explosive strength and EMGactivity to the same extent as the HCgroup. Moreover, the progressivestrength training showed immediatebenefits on subjectively perceivedfatigue, depression, and neck pain oftraining patients with FM.

A similar maneuverability of theneuromuscular system occurs inwomen with FM and healthywomen. ST is safe and can beused to decrease the impact ofFM in the neuromuscular system

Hakkinenet al., (2002);RCT

21 womencom FM,(ST and CG)and 12 HCAgeTF: 39 ±6 yearsCG: 37 ±5 yearsGS: 37 ±6 years

Duration: 21 weeks;Weekly frequency: 2; Series: 3–5series per exercise; Intensity:40–80% of 1RM; Repetitions:Initially 10–20, from the 14thweek; 5–8.Exercises: leg press, extensionand flexion of the knee, elbowand trunk, pulled high, adductionand abduction of the legsAdherence to ST: 100%

Maximal force increased by 18 ± 10%in the FM group, and by 22 ± 12%in the HC, while in the CG it remainedunchanged. Maximum integratedEMG of the agonists (VL + VM/2)increased in HC by 22% and in theFM by 19%. Significant increases inthe CSA of the QF were observed at5 to 12/15 femur in FM and at 3 to12/15 femur in HC, while in FM theCSA remained unchanged. Asignificant acute increase took placein the mean concentration of GH atpre-training in HC and in the FM,while at post-training the elevationsafter the loading remained elevatedup to 15 min in HC and up to30 min post-loading in the FM.

The time of neuromuscular andST adaptations and the basallevels of anabolic hormones inwomen with FM are similar tohealthy women

Jones et al.,(2002); RCT

68 women(ST andFLEX);AgeTF: 49.2 ±6.36 yearsCG: 46.4 ±8.56 years

Duration: 12 weeks;Weekly frequency: 2 Initially 1 seriesof 4–5, and progressively up to 12.Exercises: The main muscle groupswere worked, but exercises were notspecified.Adherence to ST:85%

No statistically significant differencesbetween groups were found onindependent t tests. Paired t testsrevealed twice the number ofsignificant improvements in thestrengthening group compared tothe stretching group. Effect sizescores indicated that the magnitudeof change was generally greater inthe strengthening group than thestretching group.

The ST group decreased the totalpain score, the number of tenderpoints, increased leg strength,shoulder strength, improvedquality of life and reduceddepression. ST showed betterresults than FLEX.

Valkeinenet al., (2004);RCT

36 women(26 FM and10 HC)AgeST: 60.2 ±2.5 yearsCG: 59.1 ±3.5 yearsHC: 64.2 ±2.7 years

Duration: 21 weeks;Weekly frequency: 2; Initially 3 seriesof 15–20 progressively up to 4 seriesof 8–12 and up to 5 series of 5–10 .Exercises: The main muscle groupswere worked, but exercises were notspecified.Adherence to ST: 100%

The mean increases in maximalextension force during the trainingperiod in groups FM and in HC were32 ± 33% and 24 ± 12% respectivelyand those of flexion were 13 ± 20%and 24 ± 17%. Explosive force of theextensors increased in both FM andin HC. The integrated EMGs of thevastus lateralis and medialis musclesincreased in both FM and HC. Muscleforces and EMGs in group CGremained at the basal level. Walkingspeed, stair-climbing time and theHAQ index improved in group FM.The changes in the number of tenderpoints and in perceived symptomswere in favors of the training groupFM.

It improved the functionalcapacity and the strength in theextensor and flexor muscles ofthe knee in both groupssubmitted to the TF (FM andhealthy). Patients with FMrespond similarly to TF thathealthy people of the same age.

Valkeinenet al., (2005);RCT

26 women (ST andCG);AgeST: 60 ±2 yearsCG: 59 ±4 years

Duration: 21 weeks;Weekly frequency: 2; Initially 3 seriesof 15–20; weeks 15 to 21 went to5–10. Intensity: progressive increaseof 40% to 80% of 1 RM Exercises: 6to 7 for the main muscle groupsAdherence to ST: not reported the

All patients were able to completethe training. In FM strength trainingled to increases of 36% and 33% inmaximal isometric and concentricforces, respectively. The CSAincreased by 5% and the EMGactivity in isometric action by 47%

The ST increases strength, cross-sectional area and voluntarymuscular activation in elderlywomen with FM. Patients withFM can be submitted to higherintensities without increasingsymptoms


Table 2 Characteristics and results of experimental studies with strength training for patients with fibromyalgia syndrome (Continued)

Study andDesign


number of dropouts and in concentric action by57%. Basal serum hormoneconcentrations remainedunaltered during strengthtraining. The subjectiveperceived symptomsshowed a minor decreasingtendency (ns). No statisticallysignificant changes occurredin any of these parametersin CG.

Kingsleyet al., (2005);RCT

29 women(ST and CG);AgeST: 45 ± 9 yearsGC: 47 ± 4 years

Duration: 12 weeks;Weekly frequency: 2; 1 serie of 8–12Intensity: 60 to 80% of 1RMExercises: Supine, extension andflexion of knee and elbow, low row,shoulder and lumbar developmentAdherence to ST: 54%

The strength group significantlyimproved upper and lower bodystrength. And upper-bodyfunctionality measured by theContinuous-Scale Physical FunctionalPerformance test improved significantlyafter training. Tender point sensitivityand fibromyalgia impact did not change.

At the end of study was asignificant increase in musclestrength and improvement infunctional capacity componentsin the ST group.

Valkeinenet al., (2006);Non RCT

23 women(13 ST and 10 CG)AgeST: 60 ± 2 yearsCG: 54 ± 3 years

Duration: 21 weeks;Weekly frequency: 2 Intensity:Started with 50% of 1RM andprogressively up to 80%; Exercises:two Exercises for knee extensorsand 4–5 Exercises for the rest ofthe bodyAdherence to ST: 100%

The ST led to large increases in maximalforce and EMG activity of the musclesand contributed to the improvement inloading performance (average load/set)at week 21. The fatiguing loadingsessions typically applied in strengthtraining before and after theexperimental period caused remarkableand comparable acute decreases inmaximal force and increases in bloodlactate concentration in both groups.Acute exercise-induced muscle painincreased similarly in both groups, andthe pain level in women with FM waslowered after the 21-week trainingperiod.

An increase in maximal strength,blood lactate concentration anddecrease in pain of the ST groupwas observed.

Bircan et al.(2008); RCT

26 women(ST and AE)AgeST: 46 ± 8,5 yearsAE: 48.3 ± 5.3 years

Duration: 8 weeksWeekly frequency: 3 Initially 1 serieof 4 repetitions and progressively upto 12 repetitions; Exercises were notspecified, however, free weightswere used and the patient’s bodyweightAdherence to ST: 100%

There were significant improvements inboth groups regarding pain, sleep,fatigue, tender point count, and fitnessafter treatment. HAD-depression scoresimproved significantly in both groupswhile no significant change occurred inHAD-anxiety scores. Bodily pain subscaleof SF-36 and physical componentsummary improved significantly in theAE group, whereas seven subscales ofSF-36, physical component summary,and mental component summaryimproved significantly in the ST group.

Aerobic exercise andstrengthening exercise weresimilarly effective at improvingsymptoms, tender point count,fitness, psychological status,and quality of life in fibromyalgiapatients.

Figueroaet al. (2008);RCT

19 women(10 FM and 9 HC)AgeST:50 ± 10 yearsHC: 49 ± 8 years

Duration: 16 weeksWeekly frequency: 21 serie of 8–12 repetitions; Intensity:Initially 50% 1RM and progressivelyup to 80%;Exercises: Supine, knee extensionand flexion, Leg press, low row,shoulder development (performedon machine)Adherence to ST: 67%

RR interval, total power, log transformed(Ln) squared root of the standarddeviation of RR interval (RMSSD), low-frequency power and BRS were lower,and HR and pulse pressure were higherin women with FM than in healthycontrols. After ST, mean (SEM) totalpower increased, RMSSD increasedand Ln of high-frequency powerincreased in women with FM. Upperand lower body muscle strengthincreased by 63% and 49%, and painperception decreased by 39% inwomen with FM. There were nochanges in BRS, HR and BP after ST.

The ST improves heart ratevariability, parasympatheticactivity, pain and the strengthof women with FM withautonomic dysfunction.

Kingsley 18 women Duration: acute effect Variables were similar in both groups The results showed lower muscle



Study andDesign


et al. (2009);Non RCT

(FM and HC)Age48,0 years(21–59 years)

One session30 min of ST, 1 serie of 12;Exercises: 10 exercises, werenot specified.Adherence to ST: 100%

at rest. HFnu decreased incontrols and increased inwomen with FM post. LFnuincreased in controls anddecreased in women with FM.The LFnu/HFnu ratio increasedin controls with no change inwomen with FM, and BRSdecreased in controls but notin women with FM.

strength in the FM group andafter acute ST, women with FMresponded differently fromcontrols, demonstrated by lowersympathetic and higher vagalmodulation without alteringbaroreceptor reflex sensitivity.

Pantonet al. (2009);RCT

21 women(ST e ST-C);AgeST: 50 ± 7 yearsST-C: 47 ± 12 years

Duration: 16 weeks;Weekly frequency: 2; 1 serie of 8–12repetitions; Exercises: Supine, kneeextension and flexion, Leg press, lowrow, shoulder development(performed on machine).Adherence: 82.8%

Both groups increased upperand lower body strength. Therewere similar improvements in FMimpact in both groups. Therewere no group interactions forthe functionality measures. Bothgroups improved in the strengthdomains; however, only ST-Csignificantly improved in the pre-to postfunctional domains offlexibility, balance and coordination,and endurance.

The ST improved FM impact onquality of life and strength. Thepractice of chiropractic inconjunction with TF assisted inadherence and functional capacity

Kingsleyet al. (2010);Non RCT

29 women(9 FM and 20 HC)AgeFM: 42 ± 5 years;HC: 45 ± 5 years

Duration: 12 weeks;Weekly frequency: 2; 3 series of 12repetitions; Intensity: Initially 50%1RM and progressively up to 85%;Exercises: Supine, extension andflexion of the knee, Leg press, lowrow (performed in machine)Adherence to ST: 88%

There was no group-by-timeinteraction for any variable.Number of active tenderpoints, myalgic score, and FIQscore were decreased after STin women with FM. Heart rateand natural log (Ln) highfrequency (LnHF) were recovered,whereas Ln low frequency (LnLF)and LnLF/LnHF ratio wereincreased 20 min after acute legresistance exercise. There wereno significant effects of ST onHRV at rest or postexercise.

The ST increased strength inboth groups and reduced painand number of PT in patientswith FM. The practice of STdoes not change the restingHR, nor the variability of HRcompared to healthy subjects.

Kingsleyet al. (2011);Non RCT

23 women(9 FM and 14 HC);AgeFM: 42 ± 5 yearsHC: 45 ± 5 years

Duration: 12 weeks;Weekly frequency: 2; 3 series of 12repetitions; Intensity: Initially 50–60%1RM Exercises: Supine, extensionand flexion of the knee, Leg press,low row (performed in machine)Adherence to ST: 88%

Aortic and digital diastolic bloodpressure (DBP) were significantlydecreased and aortic and digitalpulse pressures (PP) weresignificantly increased after acuteexercise before ST. Acute resistanceexercise had no effect on HR, wavereflection (augmentation index andreflection time), digital, or aorticsystolic BP. ST improved musclestrength without affecting acuteDBP and PP responses.

The results suggest that a leg-resistance exercise producespost-exercise diastolichypotension and does not alteraortic systolic blood pressureand HR. In addition, vascularresponses at rest and post-exercise are not altered after12 weeks of ST inpremenopausal women

Kayo et al.(2012); RCT

90 women withFM (30 ST, 30 AEand 30 CG)AgeST: 46.7 ± 6.3 years;AE: 47.7 ± 5.3 years;CG: 46.1 ± 6.4 years

Duration: 16 weeks;Weekly frequency: 3; 3 series of 10repetitions;Exercises were not specified,however, free weights were usedand the patient’s body weightAdherence to ST: 73,5

All 3 groups showed improvementafter the 16-week treatmentcompared to baseline. At the28-week follow-up, pain reductionwas similar for the AE and STgroups, but different from thecontrol group. At the end of thetreatment, 80% of subjects in thecontrol group took pain medication,but only 46.7% in the AE and 41.4%in the ST groups. Mean FIQ totalscores were lower for the AE andST groups compared with thecontrol group.

The ST was as effective as AEin reducing pain in relation toall study variables.

Hooten et al.(2012); RCT

72 FM (36 ST and36 AE)

Duration: 3 weeks;Weekly frequency: 2; 1 serie of

Significant improvements in painseverity, peak Vo2, strength, and

The ST was effective in reducingpain in relation to all study



Study andDesign


AgeST 47.3 ±10.1 yearsAE 45.8 ±11.5 years

10 repetitions;Exercises: Flexion and extensionof the knee and armAdherence to ST: 94,5%

pain thresholds were observedfrom baseline to week 3 in theintent-to-treat analysis; however,patients in the aerobic groupexperienced greater gains (inpeak Vo2) compared to thestrength group.

variables. ST practice reducedpain significantly, but there wasno difference in relation to AE.

Gavi et al.(2014); RCT

76 FM (35 ST and36 FLEX)AgeST: 44.34 ±7.94 yearsFLEX: 48.65 ±7.60 years

Duration: 16 weeks;Weekly frequency: 2; 1 serie of 10repetitions; Intensity: 45% 1RMExercises: Supine, extension andflexion of the knee, elbow andshoulder, Leg press, low paddling,fly, plantar flexionAdherence to ST: 87,5%

The ST group was more effectiveto strength gain for all musclesand pain control after 4 and 16weeks. The FLEX group showedhigher improvements in anxiety.Both groups showedimprovements in the qualityof life, and there was nosignificant difference observedbetween the groups. There wasno change in the HRV of the STand FLEX groups.

There was an increase infunctionality, depression, qualityof life in both groups, with nostatistical difference betweenthem. There was greaterreduction of pain in the ST group.

Larsson et al.(2015); RCT

130 FM (67 ST,63 RT)AgeST: 50.81 ±9.05 years;RT: 52.10 ±9.78 years

Duration: 15 weeksWeekly frequency: 2 Intensity:increased progressivelyExercises: The main muscle groupswere worked, but exercises werenot specified.Adherence to ST: 71%

Significant improvements werefound for isometric knee-extensionforce, health status, current painintensity, 6MWT, isometric elbowflexion force, pain disability, andpain acceptance in the ST groupwhen compared to the CG. Differedsignificantly in favor of the ST groupat post-treatment examinations. Nosignificant differences between STgroup and the active CG were foundregarding change in self-reportedquestionnaires from baseline to13–18 months.

The ST was considered a viableexercise mode for women withFM, improving muscle strength,with a significant improvementin health-related quality of lifeand current pain intensity,when assessed immediately after the intervention.

Palstamet al. (2016);Non RCT

67 womencom FM (67 ST)Age51 ± 9.1 years

Duration: 15 weeks;Weekly frequency: 2; Intensity:Initially 40% 1RM and progressivelyup to 80%;Exercises: The main muscle groupswere worked, but exercises werenot specified.Adherence to ST: 71%

Reduced pain disability wasexplained by higher pain disabilityat baseline together with decreasedfear avoidance beliefs about physicalactivity. The improvements in thedisability domains of recreation andsocial activity were explained bydecreased fear avoidance beliefsabout physical activity togetherwith higher baseline values of eachdisability domain respectively. Theimprovement in occupationaldisability was explained by higherbaseline values of occupationaldisability.

The ST reduces pain, inabilityand fear of practicing Physicalexercises and increased strengthand level of physical activity.

Ericssonet al. (2016);RCT

105 women(56 ST and 49 RT)Range of age22–64 years

Duration: 15 weeks;Weekly frequency: 2; Intensity:Initially 40% 1RM and progressivelyup to 80%;Exercises: The main muscle groupswere worked, but exercises werenot specified.Adherence to ST: 71%

A higher improvement was foundat the post-treatment examinationfor change in the ST group; ascompared to change in the activeCG in the MFI-20 subscale of physicalfatigue. Sleep efficiency was thestrongest predictor of change in theMFI-20 subscale general fatigue.Participating in resistance exerciseand working fewer hours per weekwere independent significant predictorsof change in physical fatigue.

The ST group significantlyreduced general, physical andmental fatigue and improvedsleep efficiency in relation tothe relaxation group; depressionand anxiety did not decline afterthe intervention

Martinsenet al. (2017);

Non RCT

54 women (31ST and 23 HC)AgeST: 49 ± 6

Duration: 15 weeksWeekly frequency: 2Exercises: exercises were notspecified.

The FIQ ratings decreased followingexercise in patients with FM,suggesting an improvement of FMsymptoms. Furthermore, for the

The intervention had differenteffects on the speed ofcognitive processing duringSCWT in patients with FM and


has favorable results, such as reducing physical and psy-chological symptoms. However, there are still gaps thatneed to be investigated.Concerning the ST sessions, it was observed that there

is no specific training protocol for patients with FM; thus,the researchers developed their own protocol. Jones et al.[45] submitted the patients to a series of four to five repe-titions, progressively increasing the number of repetitionsup to 12. This protocol was similar to that used by Bircanet al. [42], who instructed patients to perform a series offour repetitions and progressively increased the repetitionsby up to 12. Kingsley et al. [28] and Figueroa et al. [49]also submitted the patients to a series in each exercise;

however, from the beginning of the intervention, the pa-tients were instructed to perform from 8 to 12 repetitions.As the first studies analyzed were published in 2001 and2002, and at that time there was little knowledge aboutthe development of the disease and the effects of ST onthe patients, those first studies chose to use low load andseries. On the basis of the results of the earlier studies,more studies were performed and chose to use moreseries with more repetitions from the beginning [24, 27,44, 48]. Despite some differences in the protocols, the in-tensity of the exercises increased gradually. In some stud-ies, the intensity reached 80% of 1RM at the end of theintervention [25, 27]. Another issue concerns weekly


Study andDesign


HC: 47 ± 2 Adherence to ST: 65,5% SF-36 PCS ratings we found astatistically significant effect ofgroup and intervention, but nosignificant interaction betweenthe factors, thus showing thatexercise improved ratings ofSF-36 PCS in both groups.

healthy controls. We foundevidence of increased amygdalaactivation. In contrast, HCshowed decreased RTs inincongruent and congruentstimuli. Exercise had no effecton distraction-induced analgesiaor pressure pain thresholds inany of the groups but decreasedthe overall severity of FMsymptoms.

Andrade,Vilarino eBevilacqua(2017); NonRCT

52 FM (31 ST and21 CG)AgeST: 54.42 ± 7.16CG: 53.10 ± 8

Duration: 8 weeksWeekly frequency: 3 Exercises: kneeextension, knee flexion, bench press,fly, adductors, low rowing, highpulley, elbow extension, lateral raise,arm curl, standing calf raise, andabdominal crunch.Adherence to ST: 81,5

After 8 weeks of intervention,significant differences werefound between groups insubjective quality of sleep,sleep disturbance, daytimedysfunction, and total sleepscore. The correlation analysisusing Spearman’s test indicateda positive relationship betweenthe variables of pain intensityand sleep quality; when painintensity increased in patientswith fibromyalgia, sleep qualityworsened.

A significant relationship wasfound between pain level andsleep disturbances in FMpatients, and it was found thatthe higher the pain, the worsethe sleep quality of thesepatients. The ST group reducedlevels of sleep disturbance after8 weeks of intervention.

Assumpçãoet al. (2017);RCT

53 FM (19 ST, 18FLEX E 16 CG)AgeST: 45.7 ± 7.7FLEX: 47.9 ± 5.3CG: 46.9 ± 6.5

Duration: 12 weeksWeekly frequency: 2Exercises: eight repetitions ofstrengthening exercises for thefollowing muscles triceps sural, hipadductors and abductors, hip flexor,shoulder flexor and extensor,anterior and posterior deltoids,pectoralis major and rhomboidsAdherence to ST: 89,5%

The ST group had the lowestdepression score and; the controlhad the highest score of morningtiredness and stiffness, and thelowest score of vitality. In theclinical analyses, the stretchinggroup had important improvementin quality of life for all SF-36 domains,and the strengthening group hadimportant improvements in theimpact on FM symptoms measuredby the FIQ total score and in thequality of life for SF-36 domainsof physical functioning, vitality,social function, role emotional andmental health.

The ST was more effective toreducing depression, whilestretching exercises was betterto improving quality of life,especially physical functioningand pain.

LEGEND: FM Fibromyalgia, HC Healthy Control, RCT Controlled and Randomized Study, TP Tender Points, AE Aerobic Group, RT Relaxation Therapy, RM 1 MaximumRepeat, ST Strength Training, ST-C Strength Training and chiropractic, FLEX Flexibility training, HR Heart Rate, HRV Heart Rate Variability, CG Control Group, NMSNeuro-muscular system, SCWT Test of colored words Stroop, RTs long reaction times, FIQ Fibromyalgia Impact Questionnaire, SF-36 36- Item Short Form Survey,PCS Physical Component, MCS Mental Components, HAD Hospital Anxiety and Depression Score, 6MWT 6 min walking test, PGIC patient global impression ofchange, VAS Visual Analogue Scale, MFI-20 Multidimensional Fatigue Inventory, CSA cross-sectional area, QF quadriceps femoris, LF low-frequency, GH growthhormone, HAQ Health Assessment Questionnaire, EMG Surface electromyographic, Hfnu normalized high-frequency, Lfnu normalized low-frequency, RTsreaction times


frequency, but this differed slightly between 2 and 3weekly sessions. Despite the differences in the protocols, itwas observed that, in general, the studies followed the rec-ommendations of the American College of Sports Medi-cine for beginners in ST.With regard to the main symptoms, there was a

greater interest in pain, strength, quality of life, HRV,and depression. Pain is the main symptom of FM and isassociated with other symptoms such as depression,sleep disorders, and poor quality of life [24, 56]; thus,finding treatments that improve these symptoms are ofcrucial clinical relevance for patients. The results of thepresent review demonstrate that the pain of patientswith FM is significantly reduced by the ST intervention.Valkeinen et al. [53] evaluated 23 women with FM, ofwhom 13 were submitted to 2 ST sessions for 21 weeksand 10 were part of the control group. At the end of the21 weeks of intervention, significant improvement inpain was observed. Other studies examined the effect ofshorter periods of ST, and found that pain can be

reduced in a short time. Hooten et al. [30] analyzed theeffect of 3-week ST on pain. Participants performed 2weekly sessions, consisting of a series of 10 repetitionsof knee and elbow flexion and extension exercises. Atthe end of the study, a significant reduction of pain wasobserved. This result is interesting for health profes-sionals and for patients with FM, because it demon-strates that ST can help reduce symptoms in a fewweeks and with few exercises.Studies indicate that patients with FM have less

strength and reduced functional capacity compared withhealthy persons of the same age and without the disease[57]. The reduced muscle strength of patients with FMmay be related to pain; because of pain, it is commonfor patients to avoid making physical efforts. However,studies that aimed to verify the responses of patientswith FM after muscular effort showed positive results. Instudies that applied ST, strength and hypertrophy weresimilar between patients with and those without thedisease.

Fig. 2 Risk of bias in the studies analyzed


The first studies in this sense were those of Hakkinenet al. [38], Hakkinen et al. [51], Valkeinen et al. [41] andValkeinen et al. [52]. The first 2 studies analyzed the ef-fect of 21-week ST in patients with FM, and comparedthe results with those of healthy persons. From the re-sults of these studies, it can be observed that there wasan increase of force, activation, and hypertrophy in theST group and in controls. Hakkinen et al. [51] verifiedan increase of 18% in the muscular strength of patientswith FM, and of 22% in the control group, concludingthat the neuromuscular adaptations derived from ST aresimilar between patients with FM and healthy persons.Reinforcing this result, Valkeinen et al. [41] observed asignificant increase of the strength in the extension andflexion of the knee in patients with FM [33% and 20%,respectively], whereas in the control group the gainswere 12% and 17%, respectively. Valkeinen et al. [52]that analyzed strength found that after 21 weeks of ST,patients with FM had a 36% increase in isometric forceand 33% in concentric force. In addition, the authorsverified a 5% increase in the cross-sectional area of thethigh and increased activation by 57%. After analyzingthe results, the authors concluded that ST is safe for pa-tients with FM and that the patients can undergo train-ing with higher intensities.Another variable that was investigated in the studies

was the HRV. Some authors suggested that FM occurs be-cause of dysregulation of the central nervous system [6,8], causing an autonomic dysfunction that induces the ap-pearance of some symptoms such as fatigue and anxiety.Figueroa et al. [49] verified the heart rate behavior of pa-tients with FM who also had autonomic dysfunction. Theresearchers subjected the patients to 16 weeks of ST andverified improvements in HRV, parasympathetic activity,and pain reduction. Kingsley et al. [27] compared the ef-fects of 12 weeks of ST on patients with FM and healthywomen, in terms of various symptoms such as pain, num-ber of tender points, impact of FM on quality of life, andHRV. The results showed an increase in strength in bothgroups, besides the reduction of pain and tender points inpatients with FM; however, in terms of the behavior ofHRV, no significant difference was observed between pa-tients with FM and the healthy group. In contrast, in thestudy of Kingsley et al. [43] that aimed to verify the auto-nomic modulation of patients with FM after a ST session,the results demonstrated that patients with FM had alower sympathetic response and greater vagal modulation,without altering the baroreflex sensitivity, a response dif-ferent from that presented by the control group. Concern-ing a possible autonomic dysfunction in patients with FM,further studies need to be carried out in order to reach aconclusion.Other symptoms investigated were quality of life, de-

pression, and sleep disturbance. As quality of life is a

variable that is directly related to other symptoms, the im-provements observed in the other symptoms suggest thatthe quality of life could also be expected to increase. Inthe study of Gavi et al. [29], significant improvements inpain, functionality, quality of life, and depression werefound after 16 weeks of ST. Similar results were found byLarsson et al. [54] and Palstam et al. [55]. In the firststudy, there was a reduction in pain and an increase instrength and quality of life. In the second study, inaddition to the results seen in previous studies, the re-searchers noticed a reduction in the fear of performingexercises. With regard to sleep disturbance, some studiesfound a reduction after ST intervention [24, 25]. Inaddition, sleep quality correlated with pain, with patientshaving less pain experiencing less sleep disorders [24].With the new possibility of using ST as an alternative

treatment for patients with FM, some researchers beganto compare the effects of ST with those of other physicalexercise interventions. In the study of Bircan et al. [42],13 women with FM were submitted to aerobic exerciseand 13 were submitted to ST. The researchers foundthat both interventions have benefits for patients, in-cluding reduction of pain, fatigue, sleep disorders, anddepression, and improvement of aerobic capacity. How-ever, no significant improvements in anxiety were ob-served in either group. In the studies by Kayo et al. [48]and Hooten et al. [30], the effects of ST were also com-pared with those of aerobic exercise. It was noted thatthe 2 interventions presented similar results, particularlyin reducing the pain of patients. In addition, other stud-ies compared ST with relaxation or flexibility exercises.Assumpção et al. [40] verified the effects of ST and flexi-bility exercises after 12 weeks of intervention. The re-sults demonstrated that ST is more effective in reducingdepression, whereas flexibility exercises are better at im-proving the quality of life, especially physical functionand pain. Gavi et al. [29] found similar results: ST andflexibility training were effective for reducing symptoms;however, the best results in terms of pain were found inthe ST group. The study of Jones et al. [45] also com-pared ST and flexibility training, and verified that bothinterventions are effective; however, the most significantresults were found in the ST group. Lorena et al. [58]performed a systematic review on the effects of stretch-ing in patients with FM, and reported the importance ofthis intervention in improving the physical and mentalaspects of patients. Nevertheless, they emphasized theneed for studies with greater methodological rigor. Thesame can be emphasized in the present review: the posi-tive effect of ST in patients with FM is visible, but it isnecessary to carry out more studies with greater meth-odological rigor to address possible gaps.Another interesting result is about adherence to treat-

ments. It is known that patients with FM have difficulties


adhering to the practice of physical exercise; however, fewstudies reported the adherence of patients to the interven-tions [59, 60]. In the present review, the mean adherencepercentage was 84%, a result similar to that of the studyby Sanz-Baños et al. [59] in patients undergoing aerobicexercises [adherence percentage 87.2%]. This result is afurther indication that ST can be used as part of the treat-ment for patients with FM, because in addition to improv-ing the symptoms, the patients show high adherence tothe intervention.Concerning the strengths and limitations of the study,

we were able to verify through a broad literature reviewthat ST improves the symptoms of patients with FM;however, some studies presented a high risk of bias andfurther studies are needed to consolidate the obtainedresults. In addition, future reviews including the gray lit-erature are warranted in order to identify other studieson the subject.

ConclusionIn conclusion, ST had positive effects on physical andpsychological symptoms, in terms of reducing pain, thenumber of tender points, and depression, and improvingmuscle strength, sleep quality, functional capacity, andquality of life. Intervention protocols should start at lowintensity (40% of 1RM) and gradually increase the inten-sity. ST should be performed 2 or 3 times a week to ex-ercise the main muscle groups. The current studiesshowed that ST is a safe and effective method of im-proving the major symptoms of FM and can be used totreat patients with this condition.

Additional file

Additional file 1: Search strategies at PubMed. (PDF 94 kb)

Abbreviations1RM: One maximum repetition; FM: Fibromyalgia; HRV: Heart Rate Variability;PE: Physical Activity; ST: Strength Training

AcknowledgmentsThe authors thank FAPESC (Foundation for Research and Innovation of theState of Santa Catarina) for financial support through a research grant(Project No. 2442-2011/12), CAPES for a Master scholarship (grant No.02/2017), and the State University of Santa Catarina for a UDESC studyopportunity.

FundingFoundation for Research and Innovation of the State of Santa Catarina grant(Project No. 2442–2011/12).

Authors’ contributionsA.A., S.R.A.K, S.S.M, T.L.A.P drafted the manuscript. S.R.A.K, V.T.G., S.S.M., carriedout the analysis. All authors discussed the results, commented on themanuscript and approved the final draft of the manuscript.

Ethics approval and consent to participateNot applicable.

Consent for publicationNot applicable.

Competing interestsAlexandro Andrade, Ricardo de Azevedo Klumb Steffens, Sofia MendesSieczkowska, Leonardo Alexandre Peyré Tartaruga and Guilherme TorresVilarino declare that they have no conflict of interest.

Publisher’s NoteSpringer Nature remains neutral with regard to jurisdictional claims in publishedmaps and institutional affiliations.

Author details1Health and Sports Science Center, CEFID / Santa Catarina State University –UDESC, Florianópolis, SC, Brazil. 2Laboratory of Sports and ExercisePsychology - LAPE, Florianópolis, SC, Brazil. 3Regional University of Blumenau- FURB, Blumenau, SC, Brazil. 4Human Movement Sciences andPneumological Sciences, UFRGS- Federal University of Rio Grande do Sul,Porto Alegre, RS, Brazil. 5Research Laboratory of Exercise – LAPEX, PortoAlegre, RS, Brazil.

Received: 23 March 2018 Accepted: 28 September 2018

References1. Wolfe F, Smythe HA, Yunus MB, Bennett RM, Bombardier C, Goldenberg DL,

et al. The American College of Rheumatology 1990 criteria for theclassification of fibromyalgia. Arthritis Rheum. 1990;33(2):160–72.

2. Wolfe F, Clauw DJ, Fitzcharles M-A, Goldenberg DL, Häuser W, Katz RL, et al.2016 Revisions to the 2010/2011 fibromyalgia diagnostic criteria. Seminarsin arthritis and rheumatism. 2016;46:319-29.

3. Wolfe F, Clauw DJ, Fitzcharles MA, Goldenberg DL, Katz RS, Mease P, et al.The American College of Rheumatology Preliminary Diagnostic Criteria forfibromyalgia and measurement of symptom severity. Arthritis Care Res.2010;62(5):600–10 PubMed PMID: WOS:000280979600004.

4. Borchers AT, Gershwin ME. Fibromyalgia: a critical and comprehensivereview. Clin Rev Allergy Immunol. 2015;49(2):100–51 PubMed PMID:WOS:000362902500002.English.

5. McDowell CP, Cook DB, Herring MP. The effects of exercise training onanxiety in fibromyalgia patients: a meta-analysis. Med Sci Sports Exerc. 2017;49(9):1868–76 PubMed PMID: 28419024.Epub 2017/04/19.eng.

6. Häuser W, Ablin J, Fitzcharles M-A, Littlejohn G, Luciano JV, Usui C, et al.Fibromyalgia. Nature reviews Disease primers. 2015;1:15022.

7. Andrade A, Vilarino GT, Sieczkowska SM, Coimbra DR, Steffens RAK, Vietta GG.Acute effects of physical exercises on the inflammatory markers of patients withfibromyalgia syndrome: a systematic review. J Neuroimmunol. 2018;316:40–9.

8. Sluka KA, Clauw DJ. Neurobiology of fibromyalgia and chronic widespread pain.Neuroscience. 2016;338:114–29 PubMed PMID:WOS:000386338200008.English.

9. Hauser W, Klose P, Langhorst J, Moradi B, Steinbach M, Schiltenwolf M, et al.Efficacy of different types of aerobic exercise in fibromyalgia syndrome: asystematic review and meta-analysis of randomised controlled trials. ArthritisRes Ther. 2010;12(3):R79 PubMed PMID: 20459730. PMCID: PMC2911859.Epub 2010/05/13.eng.

10. Arnold LM. Biology and therapy of fibromyalgia - New therapies infibromyalgia. Arthritis Res Ther. 2006;8(4):20 PubMed PMID: WOS:000240985200002.English.

11. Hauser W, Bernardy K, Arnold B, Offenbacher M, Schiltenwolf M. Efficacy ofmulticomponent treatment in fibromyalgia syndrome: a meta-analysis ofrandomized controlled clinical trials. Arthritis Rheum. 2009;61(2):216–24PubMed PMID: 19177530. Epub 2009/01/30.eng.

12. Poole JL, Siegel P. Effectiveness of occupational therapy interventions foradults with fibromyalgia: a systematic review. Am J Occup Ther. 2017;71(1):7101180040p1–p10 PubMed PMID: 28027041. Epub 2016/12/28.eng.

13. Sanz-Baños Y, Pastor-Mira MÁ, Lledó A, López-Roig S, Peñacoba C, &Sánchez-Meca, J. Do women with fibromyalgia adhere to walking forexercise programs to improve their health? Systematic review and meta-analysis. Disabil Rehabil. 2018;40(21):2475-87.

14. Bidonde J, Busch AJ, Schachter CL, Overend TJ, Kim SY, Góes SM, et al.Aerobic exercise training for adults with fibromyalgia. Cochrane Libr. 2017.

15. Brosseau L, Wells GA, Tugwell P, Egan M, Wilson KG, Dubouloz CJ, et al.Ottawa Panel evidence-based clinical practice guidelines for aerobic fitness


https://doi.org/10.1186/s42358-018-0033-9

exercises in the management of fibromyalgia: part 1. Phys Ther. 2008;88(7):857–71 PubMed PMID: 18497301. Epub 2008/05/24. eng.

16. Brosseau L, Wells GA, Tugwell P, Egan M, Wilson KG, Dubouloz CJ, et al.Ottawa panel evidence-based clinical practice guidelines for strengtheningexercises in the management of fibromyalgia: part 2. Phys Ther. 2008;88(7):873–86 PubMed PMID: WOS:000257473000008. English.

17. Busch AJ, Webber SC, Richards RS, Bidonde J, Schachter CL, Schafer LA,et al. Resistance exercise training for fibromyalgia. Cochrane Database SystRev. 2013;(12):113 PubMed PMID: WOS:000329188500042. English.

18. Segura-Jimenez V, Castro-Pinero J, Soriano-Maldonado A, Alvarez-GallardoIC, Estevez-Lopez F, Delgado-Fernandez M, et al. The association of totaland central body fat with pain, fatigue and the impact of fibromyalgia inwomen; role of physical fitness. Eur J Pain. 2016;20(5):811–21 PubMed PMID:WOS:000373997600014.

19. Musumeci G. Effects of exercise on physical limitations and fatigue inrheumatic diseases. World J Orthop. 2015;6(10):762–9 PubMed PMID:26601057. PMCID: 4644863. eng.

20. Segura-Jimenez V, Alvarez-Gallardo IC, Carbonell-Baeza A, Aparicio VA,Ortega FB, Casimiro AJ, et al. Fibromyalgia has a larger impact on physicalhealth than on psychological health, yet both are markedly affected: the al-Andalus project. Semin Arthritis Rheum. 2015;44(5):563–70 PubMed PMID:WOS:000352923200013. English.

21. Nelson NL. Muscle strengthening activities and fibromyalgia: a review ofpain and strength outcomes. J Bodyw Mov Ther. 2015;19(2):370–6 PubMedPMID: 25892394. Epub 2015/04/22. eng.

22. Bidonde J, Jean Busch A, Bath B, Milosavljevic S. Exercise for adults withfibromyalgia: an umbrella systematic review with synthesis of best evidence.Curr Rheumatol Rev. 2014;10(1):45–79.

23. Jones KD. Recommendations for resistance training in patients withfibromyalgia. Arthritis Res Ther. 2015;17(1):258.

24. Andrade A, Vilarino GT, Bevilacqua GG. What is the effect of strengthtraining on pain and sleep in patients with fibromyalgia? Am J Phys MedRehabil. 2017.

25. Ericsson A, Palstam A, Larsson A, Lofgren M, Bileviciute-Ljungar I, Bjersing J,et al. Resistance exercise improves physical fatigue in women withfibromyalgia: a randomized controlled trial. Arthritis Res Ther. 2016;18:12PubMed PMID: WOS:000381728500002. English.

26. Larsson A, Palstam A, Lofgren M, Ernberg M, Bjersing J, Bileviciute-Ljungar I,et al. Resistance exercise improves muscle strength, health status and painintensity in fibromyalgia--a randomized controlled trial. Arthritis Res Ther.2015;17:161 PubMed PMID: 26084281. PMCID: PMC4489359. Epub 2015/06/19. eng.

27. Kingsley JD, McMillan V, Figueroa A. The effects of 12 weeks of resistanceexercise training on disease severity and autonomic modulation at rest andafter acute leg resistance exercise in women with fibromyalgia. Arch Phys MedRehabil. 2010;91(10):1551–7 PubMed PMID: WOS:000282720300010. English.

28. Kingsley JD, Panton LB, Toole T, Sirithienthad P, Mathis R, McMillan V. Theeffects of a 12-week strength-training program on strength andfunctionality in women with fibromyalgia. Arch Phys Med Rehabil. 2005;86(9):1713–21 PubMed PMID: WOS:000231747300001.

29. Gavi M, Vassalo DV, Amaral FT, DCF M, Gava PL, Dantas EM, et al.Strengthening exercises improve symptoms and quality of life but do notchange autonomic modulation in fibromyalgia: a randomized clinical trial.PLoS One. 2014;9(3):–8 PubMed PMID: WOS:000333352800023. English.

30. Hooten WM, Qu WC, Townsend CO, Judd JW. Effects of strength vs aerobicexercise on pain severity in adults with fibromyalgia: A randomizedequivalence trial. Pain. 2012;153(4):915–923. PubMed PMID: WOS:000301877300027. English.

31. Panton LB, Figueroa A, Kingsley JD, Hornbuckle L, Wilson J, St John N, et al.Effects of resistance training and chiropractic treatment in women withfibromyalgia. J Altern Complement Med. 2009;15(3):321–8 PubMed PMID:19249999. Epub 2009/03/03. eng.

32. Moher D, Shamseer L, Clarke M, Ghersi D, Liberati A, Petticrew M, et al.Preferred reporting items for systematic review and meta-analysis protocols(PRISMA-P) 2015 statement. Syst Rev. 2015;4(1):1.

33. Urrútia G, Bonfill X. La Declaración PRISMA: un paso adelante en la mejorade las publicaciones de la Revista Española de Salud Pública. Rev EspañolaSalud Públ. 2013;87(2):99–102.

34. Booth A, Clarke M, Dooley G, Ghersi D, Moher D, Petticrew M, et al. Thenuts and bolts of PROSPERO: an international prospective register ofsystematic reviews. Syst Rev. 2012;1(1):2.

35. Moher D, Booth A, Stewart L. How to reduce unnecessary duplication: usePROSPERO. Bjog-an International Journal of Obstetrics and Gynaecology.2014;121(7):784–6 PubMed PMID: WOS:000336445300032.

36. Higgins JP, Altman DG, Gotzsche PC, Juni P, Moher D, Oxman AD, et al. TheCochrane Collaboration's tool for assessing risk of bias in randomised trials.BMJ (Clinical research ed). 2011;343:d5928. PubMed PMID: 22008217. PMCID:PMC3196245. Epub 2011/10/20. eng.

37. Cohen J. A coefficient of agreement for nominal scales. Educ Psychol Meas.1960;20(1):37–46.

38. Hakkinen A, Hakkinen K, Hannonen P, Alen M. Strength training inducedadaptations in neuromuscular function of premenopausal women withfibromyalgia: comparison with healthy women. Ann Rheum Dis. 2001;60(1):21–6 PubMed PMID: WOS:000166008100005. English.

39. Martinsen S, Flodin P, Berrebi J, Lofgren M, Bileviciute-Ljungar I, MannerkorpiK, et al. The role of long-term physical exercise on performance and brainactivation during the Stroop colour word task in fibromyalgia patients.Clin Physiol Funct Imaging. 2017; PubMed PMID: 28627125. Epub 2017/06/20. eng.

40. Assumpção A ML, Yuan SL, Santos AS, Sauer J, Mango P, Marques AP.Muscle stretching exercises and resistance training in fibromyalgia: which isbetter? A three-arm randomized controlled trial. - PubMed - NCBI. 2017.

41. Valkeinen H, Alen M, Hannonen P, Hakkinen A, Airaksinen O, Hakkinen K.Changes in knee extension and flexion force, EMG and functional capacityduring strength training in older females with fibromyalgia and healthycontrols. Rheumatology. 2004;43(2):225–8 PubMed PMID: WOS:000188850000018. English.

42. Bircan C, Karasel SA, Akgun B, El O, Alper S. Effects of muscle strengtheningversus aerobic exercise program in fibromyalgia. Rheumatol Int. 2008;28(6):527–32 PubMed PMID: WOS:000254206100004. English.

43. Kingsley JD, Panton LB, McMillan V, Figueroa A. Cardiovascularautonomic modulation after acute resistance exercise in women withfibromyalgia. Arch Phys Med Rehabil. 2009;90(9):1628–34 PubMedPMID: WOS:000269938100023.

44. Kingsley JD, McMillan V, Figueroa A. Resistance exercise training does notaffect post-exercise hypotension and wave reflection in women withfibromyalgia. Appl Physiol Nutr Metab. 2011;36:254–63 PubMedPMID: WOS:000209142901618.

45. Jones KD, Burckhardt CS, Clark SR, Bennett RM, Potempa KM. A Randomizedcontrolled trial of muscle strengthening versus flexibility training infibromyalgia. J Rheumatol. 2002;29(5):1041–8 PubMed PMID: WOS:000175430100030. English.

46. Rooks DS, Silverman CB, Kantrowitz FG. The effects of progressive strengthtraining and aerobic exercise on muscle strength and cardiovascular fitnessin women with fibromyalgia: a pilot study. Arthritis Rheum-Arthritis CareRes. 2002;47(1):22–8 PubMed PMID: WOS:000173803700005. English.

47. Rooks DS, Gautam S, Romeling M, Cross ML, Stratigakis D, Evans B, et al.Group exercise, education, and. combination self-management in womenwith fibromyalgia - A randomized trial. Arch Intern Med. 2007;167(20):2192–200 PubMed PMID: WOS:000250806200005. English.

48. Kayo AH, Peccin MS, Sanches CM, Trevisani VF. Effectiveness of physicalactivity in reducing pain in patients with fibromyalgia: a blindedrandomized clinical trial. Rheumatol Int. 2012;32(8):2285–92 PubMed PMID:21594719. Epub 2011/05/20.eng.

49. Figueroa A, Kingsley JD, McMillan V, Panton LB. Resistance exercise trainingimproves heart rate variability in women with fibromyalgia. Clin PhysiolFunct Imaging. 2008;28(1):49–54 PubMed PMID: WOS:000251629100008.

50. Kingsley JD, McMillan V, Figueroa A. Resistance Exercise Training DoesNot Affect Post-exercise Hypotension And Wave Reflection In WomenWith Fibromyalgia. J Gen Intern Med. 2012;27:458 PubMed PMID:WOS:000209142901618.

51. Hakkinen K, Pakarinen A, Hannonen P, Hakkinen A, Airaksinen O, ValkeinenH, et al. Effects of strength training on muscle strength, cross-sectional area,maximal electromyographic activity, and serum hormones inpremenopausal women with fibromyalgia. Journal of Rheumatology. 2002;29(6):1287–95 PubMed PMID: WOS:000176033500028.

52. Valkeinen H, Hakkinen K, Pakarinen A, Hannonen P, Hakkinen A, AiraksinenO, et al. Muscle hypertrophy, strength development, and serum hormonesduring strength training in elderly women with fibromyalgia. Scand JRheumatol. 2005;34(4):309–14 PubMed PMID: WOS:000231312100009.

53. Valkeinen H, Hakkinen A, Hannonen P, Hakkinen K, Alen M. Acute heavy-resistance exercise-induced pain and neuromuscular fatigue in elderly


women with fibromyalgia and in healthy controls - effects of strengthtraining. Arthritis Rheum. 2006;54(4):1334–9 PubMed PMID: WOS:000236830800035. English.

54. Larsson A, Palstam A, Lofgren M, Ernberg M, Bjersing J, Bileviciute-Ljungar I,et al. Resistance exercise improves muscle strength, health status and painintensity in fibromyalgia-a randomized controlled trial. Arthritis Research &Therapy. 2015;17:15 PubMed PMID: WOS:000357248900001. English.

55. Palstam A, Larsson A, Lofgren M, Ernberg M, Bjersing J, Bileviciute-Ljungar I,et al. Decrease of fear avoidance beliefs following person-centeredprogressive resistance exercise contributes to reduced pain disability inwomen with fibromyalgia: secondary exploratory analyses from arandomized controlled trial. Arthritis Research & Therapy. 2016;18 PubMedPMID: WOS:000376372300006.

56. Andrade A, Vilarino GT, Sieczkowska SM, Coimbra DR, Bevilacqua GG, SteffensRAK. The relationship between sleep quality and fibromyalgia symptoms. JHealth Psychol. 2018. https://doi.org/10.1177/1359105317751615.

57. Larsson A, Palstam A, Bjersing J, Löfgren M, Ernberg M, Kosek E, et al.Controlled, cross-sectional, multi-center study of physical capacity andassociated factors in women with fibromyalgia. BMC Musculoskelet Disord.2018;19(1):121.

58. Lorena SB, Lima Mdo C, Ranzolin A, Duarte AL. Effects of muscle stretchingexercises in the treatment of fibromyalgia: a systematic review. Rev BrasReumatol 2015;55(2):167–173. PubMed PMID: 25440706. Epub 2014/12/03. eng.

59. Sanz-Banos Y, Pastor-Mira MA, Lledo A, Lopez-Roig S, Penacoba C, Sanchez-Meca J. Do women with fibromyalgia adhere to walking for exerciseprograms to improve their health? Systematic review and meta-analysis.Disabil Rehabil. 2017;07:1–13 PubMed PMID: 28687050. Epub 2017/07/09. eng.

60. Thomas EN, Blotman F. Aerobic exercise in fibromyalgia: a practical review.Rheumatol Int. 2010;30(9):1143–50 PubMed PMID: 20340025. Epub 2010/03/27. eng.


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A systematic review of the effects of strength training in